Next Tory attempt at NHS reform will have firmer foundations

HSJ can confidently predict that this parliament is unlikely to see any major piece of health legislation or reorganisation of NHS structure

The Conservative Party has not had full control of the NHS for 18 years. Given the scale of the victory – and that of Labour’s defeat – they could have stewardship of the service well into the next decade.

What will they do?

One thing HSJ can confidently predict is that this parliament is unlikely to see a major piece of health legislation or any kind of major reorganisation of NHS structure.

‘There is frustration in senior Tory circles at the way health lobby groups appeared to talk down Conservative pledges’

The experience of the Lansley reforms is seared into the psyche of the current generation of Tory health policymakers who have pledged to a man and woman never to take such a risk again. There is even a growing reluctance to conduct some of the “tidying up” in roles and responsibilities that some would like to see – for example, the absorption of the NHS Trust Development Authority into Monitor.

What will also not happen is the introduction of any kind of co-payment for NHS services. Acres of text and aeons of airtime may be devoted to debating such an idea, both as a way out of the NHS’s financial difficulties and as a threat to its core values. But while David Cameron remains prime minister, a coalition with the SNP is a more likely outcome.

There is considerable frustration, even anger, in senior Tory circles at the way some health lobby groups appeared to talk down Conservative pledges on NHS funding during the election.

This feeling was exacerbated when the same groups were also perceived not to provide enough challenge to claims of NHS “privatisation” or that, in general, the service was not safe in Tory hands. It is unlikely this lack of faith in Conservative commitment to the service will be forgotten in a hurry.

Delivering the forward view

That commitment manifests itself most overtly in the government’s intention to back and fund the NHS Five Year Forward View.

That is, of course, far from straight forward. Putting aside the question of where the money will come from and when it will be delivered; there is considerable scope as to how the forward view’s vision might be operationalised.

The biggest change on any likely scenario being considered last week is that a majority Conservative government will feel emboldened to support more radical strategies than it might have done before Thursday’s changing of the political guard.

‘Urgent pricing reform will remove much of the influence of providers’

That radicalism is very unlikely to mean a significant change in the role of private healthcare providers in the secondary care sector. Circle’s management of Hinchingbrooke has destroyed any appetite for similar transfers of responsibility for the foreseeable future.

The picture may be very different in primary care. The health chapter of the Conservative Party manifesto placed major emphasis on improving GP access. Should the established suppliers of primary care not respond, expect to see significant encouragement of alternative providers - some from within the NHS through the implementation of new care models, and some from outside.

The reforms to the NHS provider landscape proposed by Sir David Dalton will receive much more overt backing. His report arrived at a sensitive time for the coalition and was downplayed as a result. Now the question to be asked will be “why aren’t we doing this?”

The relationship with NHS trusts, especially the largest, will be difficult. Growing deficits will encourage direct intervention, and urgent pricing reform will remove much of the influence of providers, whose anger has only been kept below boiling point by some recent frantic behind the scenes negotiation.

Offering the Shelford Group major teaching trusts a chance to extend their influence in a safe and sustainable way as conceived by Sir David will be a useful bargaining chip.

Workforce reform and efficiency

Read the Tory manifesto carefully and you will detect a desire to encourage changes to the terms and conditions of the NHS’s clinical workforce. The desire to deliver 24/7 services is the main driver, but so is the ambition of having clinical staff more closely aligned to service improvement and efficiency goals.

The long debated questions of linking performance to pay, ensuring a more appropriate skill mix and underpinning a culture of career long learning will be back on the table – with proposed reforms to, for example, national contracts, Agenda for Change and clinical excellence awards the likely mechanisms to deliver change.

‘Mr Hunt has proved effective and has an improving relationship with Simon Stevens’

Lord Carter’s review of NHS efficiency and procurement will be given strong backing. It should not surprise anyone if the new government takes the opportunity of what is likely to be a brief honeymoon period to sort out the information governance problems that are restricting data sharing within the NHS and care services.

There is much about the current political scene reminiscent of the period between 1987 and the New Labour landslide. During that time four consecutive “one nation” conservative health secretaries put in place a series of reforms which have proved, sometimes indirectly, surprisingly resilient.

HSJ applauds the prime minister for re-appointing Jeremy Hunt as health secretary. Mr Hunt has proved effective, has an improving relationship with Simon Stevens, and made his commitment to the job very clear to HSJ before the election.

The opportunity for Mr Cameron and his health secretary is similar. To realise it they must fund the NHS properly – something that includes taking into account the effects that cuts to other public services will have on the health of the nation.

They must also maintain a delicate balance between providing challenge to the system through the right incentives and avoiding the temptation to intervene as new care models produce different outcomes, and one region is perceived to lose out when compared with another.

In a House of Commons in which many votes will be decided by a handful of rebels, that will be no easy task.

Northamptonshire CC has been granted permission by the government to use £70m of capital receipts to help balance its books after commissioners warned the council will not be able to set a balanced budget this year.

Kent CC leader Paul Carter (Con) has called any requirement for elected mayors in county devolution deals “totally insulting” as he shared an event stage with Cambridgshire & Peterborough CA mayor James Palmer (Con).

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